Specialty: Psychiatrist
Background and past contacts:
Patient, Ms. Jane Doe, a 32-year-old female, has been attending the General Adult Psychiatry Clinic for ongoing management of Generalised Anxiety Disorder (GAD) and co-morbid Major Depressive Disorder (MDD). Previous appointments on 1 August 2024 and 15 September 2024 focused on medication titration and exploring cognitive behavioural therapy (CBT) options. The current visit is a follow-up to assess the effectiveness of medication adjustments and ongoing symptom management.
Update on Employment History
Ms. Doe reports no change in her employment status. She continues to work full-time as a marketing executive.
Update on Social History
No update. Ms. Doe continues to live with her partner and reports a supportive home environment.
Update on Relationship History
No update. Ms. Doe reports her relationship with her partner remains stable and supportive.
Update on Drug and Alcohol History
No update. Ms. Doe denies any illicit drug use and reports occasional social alcohol consumption, unchanged from previous reports.
Update on Past Medical History
No update. Relevant past medical history includes well-controlled asthma, for which she uses an inhaler as needed. No known allergies.
Update on Medication History
Ms. Doe is currently taking Sertraline 100mg once daily (increased from 75mg at the last visit) and Propranolol 20mg twice daily as needed for anxiety symptoms. She reports consistent adherence to her medication regimen. No other changes since the last visit.
Update on Past Psychiatric History
Brief summary of past psychiatric history includes recurrent episodes of GAD and MDD, with initial diagnosis 5 years ago. No new psychiatric diagnoses or significant changes in presentation since the last review.
Update on Forensic History
No update.
Summary of review:
Ms. Doe reports a moderate improvement in her main anxiety symptoms since the Sertraline dosage increase. She notes a reduction in the frequency and intensity of panic attacks, from several times a week to 1-2 episodes in the past month. The duration of anxious episodes has also decreased. Her depressive symptoms, particularly low mood and anhedonia, have shown slight improvement, but she still experiences periods of fatigue and lack of motivation. The impact of symptoms on her daily activities has lessened, allowing her to engage more consistently with work and social activities, a positive change from the previous appointment where her concentration and social withdrawal were significant concerns.
She reports mild side effects from Sertraline, specifically occasional mild nausea, which has become less frequent than at the initial titration phase. Ms. Doe assesses the medication as moderately effective for her anxiety and mildly effective for her depression. She expressed concerns about the lingering fatigue and wondered if other medication options might further improve her energy levels.
Regarding the treatment plan agreed at the previous appointment, Ms. Doe engaged in online CBT resources as discussed, finding some techniques helpful for managing acute anxiety, particularly breathing exercises. She struggled to consistently apply other techniques due to fluctuating motivation. Psychoeducation was provided on the typical timeline for antidepressant effectiveness and the importance of continued adherence despite some remaining symptoms. Ms. Doe responded positively, acknowledging the gradual nature of recovery.
No new symptoms or concerns were raised during the appointment beyond her fatigue.
No negative responses to clinical questions were noted.
Mental Status Examination:
Ms. Doe presented as casually dressed and well-groomed, with good eye contact throughout the session, an improvement from the last appointment where eye contact was often averted. Psychomotor activity was normal.
Subjective mood was reported as "better than before, but still a bit flat." Her affect was congruent with her reported mood, showing a restricted range but appropriate reactivity to discussion topics, a slight improvement in amplitude from the previous visit.
Speech was of normal rate, volume, and coherence. Thought process was logical and goal-directed. No formal thought disorders were identified. She denied any delusions, overvalued ideas, or obsessive thoughts. No changes from the last appointment in this area.
She explicitly denied any hallucinations or perceptual disturbances.
Ms. Doe demonstrated good insight into her GAD and MDD, acknowledging the need for ongoing treatment and her role in managing her symptoms. She appears engaged with care, showing a consistent help-seeking stance, unchanged from the last appointment.
Risk Assessment:
Current risk factors include moderate symptoms of MDD and GAD. Ms. Doe denies any current self-harm ideation, suicidal ideation, or plans. She has no history of self-harm or suicide attempts. She denies any history of violence or aggression towards others or property. Protective factors include a supportive partner, stable employment, and good insight into her condition. No current risk factors for self-harm, suicide, or violence are identified. She has a safety plan in place, which involves contacting her partner or a mental health crisis line if her symptoms significantly worsen.
Capacity to consent to care and treatment
Ms. Doe demonstrated full capacity to consent to her care and treatment, understanding the information presented, appreciating the implications, reasoning through options, and communicating her choice effectively.
Impression
Ms. Jane Doe is a 32-year-old female presenting with ongoing GAD and MDD, currently on Sertraline and Propranolol. Biopsychosocial factors contributing to her condition include a genetic predisposition (family history of anxiety) and work-related stress. Her diagnosis remains appropriate given her persistent symptoms and functional impairment. Feedback was given to Ms. Doe regarding the positive impact of the Sertraline dosage increase on her anxiety. She acknowledged the improvements but expressed her desire for further relief from fatigue, a sentiment the clinician validated. Recommendations considered included increasing the Sertraline dose further, switching antidepressants, or adding an adjunct medication. After discussion, Ms. Doe and the clinician mutually agreed to explore the option of increasing the Sertraline to 150mg daily, with a clear understanding of potential benefits and side effects. For additional support, the recommendation for continued CBT engagement was discussed, with a specific focus on strategies for managing fatigue. Ms. Doe agreed to revisit the online CBT modules and try to implement more techniques. Her primary concern about fatigue was addressed by acknowledging its impact and discussing the plan to adjust medication, with an agreement to monitor this closely.
Plan:
* Increase Sertraline to 150mg daily, to be taken with food.
* Continue Propranolol 20mg as needed for anxiety.
* Encourage continued engagement with online CBT resources, focusing on energy management techniques.
* Follow-up appointment scheduled in 4 weeks to review medication effectiveness and side effects, and to assess fatigue levels.
(If previous session findings or any additional information is supplied in the context tab or discussed, draw comparisons and flag any significant differences in the patient's presentation, including changes in key symptoms. Additionally, populate the first paragraph of the "Background and past contacts" section using the information in the context tab.)
**Background and past contacts:**
[Past contacts including dates, types of appointments, key issues discussed, and any interventions or treatments provided](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Current and planned reasons for visit](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
**Update on Employment History**
[Any change in the patient's employment status or circumstances, if clearly mentioned in the transcript or at odds with what is documented in the context tab; if no changes, write "No update"](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
**Update on Social History**
[Any change in the patient's current social circumstances, if clearly mentioned in the transcript or at odds with what is documented in the context tab; if no changes, write "No update"](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
**Update on Relationship History**
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**Update on Drug and Alcohol History**
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[If active and ongoing drug or alcohol use is present, briefly note it here even if there is no update](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
**Update on Past Medical History**
[Any change in the patient's medical history, if clearly mentioned in the transcript or at odds with what is documented in the context tab; if no changes, write "No update"](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Relevant past medical history available in context notes or mentioned in the transcript, briefly noted even if there is no update](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Any information available on allergies](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
**Update on Medication History**
[Current medications including dosages, frequency, and any changes since the last visit](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else write "No information available".)
[If currently in the medication adjustment process, a summary of any relevant medication history](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
**Update on Past Psychiatric History**
[Brief summary of past psychiatric history and any change, if clearly mentioned in the transcript or at odds with what is documented in the context tab](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else write "No information available".)
**Update on Forensic History**
[Any change in the patient's forensic history, if clearly mentioned in the transcript or at odds with what is documented in the context tab; if no changes, write "No update"](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
**Summary of review:**
[How the patient's main symptoms, diagnosis, and concerns have changed or evolved since the last clinical review, including any change in duration, timing, location, quality, severity, or context of key symptoms](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Any new reported factors that worsen or alleviate symptoms, including self-treatment attempts and their effectiveness](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Current impact of symptoms on daily activities and work, and how this has changed since the last appointment](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Any reported side effects from medication, including negative responses to questions about side effects](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Patient's assessment of medication effectiveness, including any changes or improvements noticed](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Patient's expressed concerns or issues regarding their current medication regimen](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Progress made on the treatment plan agreed at the previous appointment, including what went well, what did not, and why](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Any psychoeducation provided by the clinician and the patient's response](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Any new symptoms or concerns raised during the appointment](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Any negative responses to clinical questions](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
**Mental Status Examination:**
[Appearance, behaviour, eye contact, and psychomotor activity, noting any changes or no changes from the last appointment](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Mood and affect: subjective self-reported mood and objective translation, together with observed affect noting congruence, reactivity, and amplitude, and any changes or no changes from the last appointment](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Speech and thought: rate, volume, coherence, and organisation of speech, followed by thought process psychopathology. Formally exclude formal thought disorders if appropriate. Describe any queried thought content abnormalities, explicitly denying or confirming delusions, overvalued ideas, obsessive or intrusive thoughts, anxious ruminations, or other relevant details, and note any changes or no changes from the last appointment](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Perception: if no hallucinations or perceptual disturbances are described, explicitly deny their presence or any behaviour suggestive of them; if hallucinations or perceptual experiences are described, document modality, characteristics, insight-related features, frequency, and duration, and note any changes or no changes from the last appointment](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Patient's insight into their difficulties, beliefs around their nature, ability to recognise limitations, help-seeking stance, and engagement with care, noting any changes or no changes from the last appointment](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
**Risk Assessment:**
[Current risk factors](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Any history of self-harm, suicidal ideation, or attempts](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Any history of violence or aggression, including towards others or property](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Protective factors such as coping skills, resilience, or support systems](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Current risk factors for self-harm, suicide, or violence](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Any safety plans or interventions currently in place](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
**Capacity to consent to care and treatment**
[Assessment of capacity or presumed capacity features, as applicable](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
**Impression:**
[Summary of the case including biopsychosocial factors contributing to the patient's condition, and rationale for why the diagnosis is appropriate](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Summary of feedback given to the patient and discussion had, clearly documenting the clinician's and patient's views on all that was discussed](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Summary of recommendations considered and discussion had, clearly documenting the clinician's and patient's views on all options discussed](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Discussion on medication in detail, including the clinician's and patient's views, ending with the option decided on](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[Discussion on any recommendations for additional support such as therapy, coaching, or resources, ending with the option decided on](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[All patient concerns or questions about management or treatment plan, and the clinician's response, ending with the action steps agreed](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
**Plan:**
[Treatment plan including any changes to medications, therapy recommendations, follow-up appointments, and any other interventions](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.)
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